It should be widely recognized that there are multiple levels of causation from immediate physiological factors all the way up to social structures. Such causal chains develop over time and across generations. SDOH does a great job in highlighting that message. The immediate cause of a heart attack is the thrombus that blocks the artery. It is rightly a 'cause' because if it is prevented or removed the heart attack does not happen. This in no way denies that there are antecedent causes of the thrombus further up the causal chain. The point for prevention efforts is to figure out, in what part of the causal chain we can intervene most effectively and that could be anywhere, most likely at multiple points on the causal chain from basic aspects of the social structure (decreasing poverty) down to the immediate physiological factors (clot busting drugs at the ER).
The focus should be on figuring out what are the most effective interventions, at any point or time on the causal chain, to generate better overall population health and reduce social inequality in population health.
Suggesting that conventional physiological risk factors and behaviors are not important parts of the causal chain by invoking the idea that they explain less than 10 or 20 or 30% of the variation in an outcome like CHD and diabetes, while technically correct, is nevertheless a partial view based on attempts to understand individual variation in risk. As I tried to point out earlier, those same risk factors, when considered at the population level do in fact account for the bulk of the cases in the population and the bulk of the absolute burden of social inequality in the outcomes. Attempting to take them off the prevention agenda because they apparently do not explain much variation in individual risk is a partial interpretation of the evidence and in my view, limits good public health practice, because we limit our scope for intervention. Physiological risk factors and behaviors matter at the population level.
This idea in no way denies the existence of political, economic and social structures that constrain the sorts of lives people can live, or that these physiological factors are socially patterned such that they are often more prevalent among the socially disadvantaged. There is no inconsistency in attempting to change both inequality and physiological risk factors in socially progressive ways.
John Lynch
Dept Epidemiology
McGill University
-----Original Message-----
From: Social Determinants of Health on behalf of Dennis Raphael
Sent: Fri 8/4/2006 7:40 AM
To: [log in to unmask]
Subject: Re: [SDOH] Supermodels and Obesity as a "cause" of diabetes?
People who jump off bridges are 1 zillion times more likely to die younger
than those who do not jump off bridges.
Is jumping off the bridge the "cause" of this difference? And can we
ignore all the preceding issues that led to this?
dr
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